Test form Signups
| Status | Expired |
|---|---|
| Misc Member Notes | LVM letting know processed membership 9-18-15 AK |
| Membership Type | Individual Plan ($99.95) |
| Your Name | Aimee Prosick |
| Phone | (570) 875-7592 |
| Date of Birth | 04/08/1976 |
| Referred by or Referral Code | Mail 9-18-15 |
| Enter Office Code | A12522 |
| Address | 120 North Broad Mountain Avenue Frackville, PA 17931 Map It |
| Total | $99.95 |
| Plan Information | |
| Newest Membership: Programmatically pick Plan Start Date Based on either new plan or their ID number here | 09/18/2015 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/18/2016 |
| Membership ID Number | 7538018929 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
